THURSDAY, MARCH 3, 2005
Session 4: Aging and Care-Giving: Ends and Priorities
in Medical Care
Daniel Callahan, Ph.D., Director of International Programs, The
CHAIRMAN KASS: While people are returning to their seats,
let me just mention that there are a few things that are at your
places. Dan Callahan, who will be presenting shortly, has left
a couple of sheets that are relevant to his presentation.
I should have mentioned this early this morning, this copy of
Cerebrum, which is a publication from the DANA forum on brain science,
is here for your interest, but especially here so that you can see
how our colleague Paul McHugh has defended the Council's interest
in the topic of neuroethics against a distinguished member of the
bioethics profession. I'm not sure whether he read the report
before criticizing or not but thanks to Paul, and he thought and
I think with him that one should see how the conversation that we
started continues and I hope will continue further.
The third thing that we have here, Bill, do you want to say a
word about that, this article? This is yours, is it not? Am I
wrong about this?
DR. HURLBUT: No. I didn't realize that Diane had
given it out to everybody. I think this is a very important thing
for us to pay attention to because it shows the significance of
the integrated organism and its power to reprogram and the potential
danger of there being persuasive arguments for actually employing
up and running organisms in the production of patient-specific tissue-type
organs. I mean, that's maybe stretching.
CHAIRMAN KASS: This is pertinent for the discussion tomorrow?
DR. HURLBUT: Yes.
CHAIRMAN KASS: Okay. Good. I think we are mostly back.
The last of our sessions today entitled "Ends and Priorities
in Medical Care," we turn from questions of the utilization
of the means to a consideration of the ends, the limits, and the
priorities amongst the ends.
And we welcome back to the Council an old and dear friend, Daniel
Callahan, who, as you recall, was with us — well, the years
run together now but at least a year ago, I think, to talk on the
research imperative, the subject of his most recent book.
Dan is co-founder of the Hastings Center, was for 27 years its
director and president, now is the Director of International Programs.
He has been a rather lonely voice raising the most fundamental
questions about medicine and the health care system, about its ends,
its limits. Among the books that have tackled these things already
18 years ago, Setting Limits: Medical Goals in an Aging Society;
What Kind of Life: The Limits of Medical Progress;The Troubled
Dream of Life: In Search of a Peaceful Death; and False
Hopes. And it's I think important that in thinking about
these questions at the end of life but in general that we not pay
attention just to the economic questions alone but to try to think
through what we are trying to accomplish and to look at some of
the fundamental assumptions on the basis of which medicine has been
proceeding. And Dan has kindly agreed to come and lead us in a
discussion of that topic.
DR. CALLAHAN: Thank you, Leon.
DR. CALLAHAN: Let me say it is a particular pleasure to
be here. Approximately 60 years ago, I was a high school swimmer
who swam at the Ambassador Hotel, which is catty-cornered to this
hotel, the hotel next to us. And from swimming, I got a scholarship
to go to Yale. When I went to Yale, my first course was swimming
philosophy. And, hence, many years later, I am back here at the
same corner. So that probably proves something or other.
The main point, I saw aging prematurely because, like many swimmers,
my times went downhill after age 20. And I sort of jokingly put
my head up out of the water and said, "Well, what else is going
on in this university?" Anyway, it is a pleasure to be here.
I am particularly pleased that John Wennberg is here because I
think what I am going to say shows how one can look at the health
care system in an entirely different way.
I have spent a lot of time reading his work, which I have profited
from, and reading the work of health economists, epidemiologists,
and others who look at the health care system. I come at it from
a somewhat different slant. And I would particularly be interested
in how John responds to all of this. I will, though, in a way use
the economic issue as a point of departure since that seems to me
a nice way in.
The national debate on the future of American health care I believe
needs to come to grips with the idea and deep value of medical progress
and technological innovation. The problem of health care cost increase
is an essential issue, and the debate cannot alone be solved I believe
by better management techniques or a stronger government or market
orientation, nothing less than a rethinking of the ideal of endless
progress in health care and medicine will be necessary.
The main focus of my ethical analysis of American health care
is focused on the problem of justice; that is to say, how to develop
a health care system to provide equitable access to health care
and if and when rationing is needed how to do that in a just way.
The justice discussions have long had an interest in the idea
of a right to health care or, alternatively, an obligation on the
part of government to provide care or for some who like the European
way and embrace the notion of solidarity as the foundation for just
Now, it seems to me one basic point that has been missing from
much of this extended discussion and debate, I don't believe
it is possible to talk meaningfully about equitable access to health
care without an effort to get straight on the goals of contemporary
medicine and particularly the way the notion of medical progress
shapes and reshapes those goals.
For instance, there have been debates for at least as long as
I have been in the field about what is the meaning of the term "medical
necessity," which one sees in much legislation, much writing.
Like some ancient mathematical questions, nobody has ever been able
satisfactorily to pin that one down. So, too, the concept of medical
futility, but newer turns out to be equally elusive.
And I think, as you know, from your earlier discussions here on
enhancement, the line between medical need and medical enhancement
has become increasingly fuzzy as well.
If one uses a sort of pie analogy of justice; that is to say,
how do you barely cut up a pie to do right by everyone, the analogy
simply doesn't work in the case of health care because the pie
continues to grow. The shape of it is absolutely irregular. And
people have different predilections about whether they think it
tastes good or it tastes bad. So immediately if you have a simple
paradigm of justice, it doesn't work well in this area.
To me, the interesting question, then, is one of progress and
innovation, which it seems to me makes it very difficult indeed
to decide what would be adequate and decent access.
For me the problem of properly understanding and deploying technology
has become the central problem in determining how medicine and health
care should, first of all, set its goals internally toward morally
good and economically sustainable goals; and, secondly, how medical
progress, its costs and social implications, should be understood
in the context of other social areas, such as jobs, education, environment;
that is to say, how we compare health needs with other social needs.
Now, a point of departure for thinking about this problem is that
of managing health care costs. This problem began appearing with
growing intensity in the 1970s, leading to cost increases of 8 to
12 percent a year over a long, long period.
There was a plateau, as many of you know, in the mid 1990s because
of the HMOs, but because of patient and physician complaints about
actually some of the most effective cost control measures, they
dropped many of those measures. And the double digit inflation
increased by the end of the 1990s.
Now we now spend, the latest government study, 1.8 trillion on
health care, 45 million uninsured, increasing I understand at an
approximate rate of one million a year, and health outcomes weaker
than many countries that spend much, much less.
The same government study recently estimated there's going
to be a doubling. Over the next 10 years, we're going to go
from 15 to 18 percent of the gross domestic product on health care.
We're going to see a doubling, actually, of the cost of 1.8
trillion to 3.6 trillion in health care costs in 10 years.
Now, to me the most interesting figure is I think the generally
agreed upon estimate of economists, that from 40 to 50 percent of
the cost increase comes either from new technologies or intensified
use of older ones, drug prices leading the way. In general, the
aging of society and public demand account together and general
inflationary increase account for the rest. But the figure of the
cost increase because of the technological factor seems to me the
important and interesting one.
There is no end in sight for increases of this magnitude. They're
helped along by the great cultural love of progress, the NIH being,
I suppose, our great national symbol of a huge investment in research.
And I've mentioned earlier in the other session the invocation
of a kind of moral obligation to carry out a war on disease.
The rising cost ultimately stems, I believe, from what I call
the infinity model of medical progress. That is the commitment
to constant and endless progress with no even ideal end in sight
or even envisioned. No matter how far one can imagine traveling
in space, there is still further one can go. No matter how good
health is, there is almost always more to be sought, if only on
the frontiers of aging.
Health is a peculiar feature that, however much health improves,
the more we spend on it. At the same time as we are worried about
health care costs going up, all the statistics show mortality dropping
in all the major disease categories and people gradually living
Thirty years ago, we spent roughly six percent of our GDP on health
care, six percent on health. It's still 6 percent on education
roughly, and it's up to 15 percent on health care.
One might really ask, what in the world is going on here? I think
while spending on education has remained static at six percent,
no one would claim we have a great education at the K.12 level.
Now, it's interesting — and one reason I particularly
came at this from the economic angle, I spent a lot of time in Europe.
And it's very striking that they're having lots of problems
Their problems aren't quite as critical or harsh as ours,
but they are worrying about the costs very much. Their cost increases
are roughly four to five percent, which is ahead of general inflation.
In every European country, their question is, how can we better
The striking thing is it doesn't matter what kind of system
you have, whether it's heavily oriented in a market direction
or heavily oriented in a universal care government.run direction,
everybody seems to be having trouble these days. So I got interested
particularly in what is the common thread in, again, the idea of
progress in technological innovations.
Now, we have had a lot of debates on health care. We should look
at this particular item in the American health care debate, which
is my effort to specify the different levels at which we have debated
the problem of health care, particularly health care costs.
I break it up into liberals and conservatives. There's a
lot of crossing of the line. So that's a bit crude in many
ways. Most of the discussion in our country has been at the level
of organization and management. And I think John Wennberg has been
one of the great practitioners.
How if we had better change the system can we cope with all of
this? Liberals have their whole bunch of schemes. And conservatives
have their bunch of schemes for doing so.
I would say that most of the discussion, particularly in the health
care journals, is focused on questions of organization and management.
And I think this shows a certain American proclivity that we are
wonderful managers and wonderful organizers. If we just put our
mind to it, we can figure out how to do this.
I guess it's a little bit like saying, you know, "We
really won't have any problem going to Mars if we can just have
a more cost-efficient NASA and develop much cheaper rockets."
Well, okay. That's possible, but I found what is frustrating
is the management approach has been going on for 30 years now and
it's not clear we have made much progress at all in figuring
out better management techniques.
The second level is what I call the government versus the market,
which has become pronounced under the George W. Bush administration.
To what extent do we want a government-run system or a market system
or if a mixed system, what should be the right proportion?
Interestingly, in this country, a lot of people, like myself,
look to greater government assistance in order to get eventually
to universal health care, a bit skeptical of the market.
And, contrast, in Europe, they hang on to universal health care,
but they are now playing around a bit with the market because I
suppose in one sense, if government is finding trouble to pay for
health care costs, the market is the only obvious way out of that
if you can't reorganize your system to deal with the cost.
The third level is the level I call social values. Liberals like
to talk like me, talk about equitable access. I've never liked
the idea of a right to health care. There's a lot of problems
I've been attracted to the European notion of solidarity,
which is a very nice idea if you live in Europe, where people have
some sense of solidarity, unlike the U.S., where we are a little
skimpy on that. If you look on the right-hand side, if you read
the market literature, you will hear lots of talk about consumer
choice, efficiency, consumer confronting costs, and particularly
the value of competition as a way of controlling costs.
I have a public health level in there because there are at least
some people who have gotten very interested in recent years in the
socioeconomic conditions between health status, income, jobs, education,
and the like, and particularly interested in the problem of how
do you promote behavioral change.
Now, this may be just my ignorance, but I don't find comparable
conservative literature from a market perspective on the question
of the socioeconomic correlates of health status, but I bring this
Finally, we come to the area that I think is common to both right
and left in that both right and left love the market. The left
loves it because a kind of invitement project commitment to infinite
progress of all kinds that it is both our right and our obligation
and our destiny to keep moving on scientifically and understanding
more. And innovation goes with that.
The market is interested because it is interested in satisfying
preferences. And you can sell people technologies. They like it.
They are willing to pay for it. And, of course, many market-oriented
people argue that the market has great side benefits to society
as a whole.
The striking thing is that there really is an interesting joining
of right and left on the question of progress, from different angles
perhaps, but both embrace it.
Now, I think, as was suggested, most of the discussion centers
on the top level, with many people believing that good management
and organization can solve the problem. And Dr. Wennberg has made
a good case that there are lots of useful things we can do.
The one line that gets no discussion at all is the idea of unlimited
progress. It, as I mentioned, is shared by liberals and conservatives
alike. In fact, I find there is a tendency to want to evade the
problem altogether, taking it as a good that requires no defense.
Some invoke a research imperative. We can get rid of these cost
problems if we spend more money on research. We will get rid of
these expensive diseases or find ways to ameliorate them and, thus,
reduce the cost.
There are some that say that we just need better medical and health
services research. And Dr. Wennberg echoed that. If we can better
understand through research how to run the system and what is wrong
with the system.
There are those, particularly one of whom includes David Cutler
and now the director — who was the person mentioned? Leon,
you had dinner with him last night. Mark McClellan, who really
have argued that yes, research and progress do drive up health care
costs and, yes, they are responsible for some of our economic problems,
but essentially it's worth it because what it ends up doing
is saving and extending life. And that itself is a valuable economic
contribution. So in one sense, they worry less about what the drive
for progress does to the economic side by virtue of its other benefits.
And, finally, there are those who argue, not a few, who basically
say, "Well, so what if we spend 18 percent of our gross domestic
product on health care? What's better than health anyway?"
Not only is it good for individuals, not only does it satisfy most
of our preferences to live longer, rather than shorter, lives, but,
again, it has all sorts of economic benefits for society. In other
words, what better way to spend their money?
Well, I happen to think that is not necessarily the better way
to spend money but in great part because it seems to me there is
no good, inherently good, reason why health care as a portion of
the money we spend in our society should wildly outrun other sectors.
Now, in putting forth — I will come to what I call sustainable
medicine at the end and lay out my specific thinking on some of
this, but I think it's important to understand that there are
other areas where we have confronted economic problems in a basic
way and we really did change out behavior.
We no longer have a supersonic airliner. No company is going
to manufacture them. No airline is going to buy them. They decided
they were not affordable. And they had environmental problems anyway.
I think we have pretty well decided, despite what President Bush
says about going to Mars, that from the future, we're going
to settle for space shuttles, unmanned spacecrafts. And, again,
it's a budget restraint.
And, finally, my example from my childhood is I grew up at a time
when Popular Mechanics and other magazines were projecting
automobiles would average 115 miles an hour over these wonderfully
engineered cantilevered highways.
Well, the fact of the matter is we don't average driving any
faster now than we did 50 years ago. We're not going to get
those fancy cantilevered highways. We are all going to have to
drive. Probably because of the increasing number of automobiles,
it's probably going to get slower and slower, not faster and
So there are other areas that have been important to our society
where we have drawn some lines and let the economic realities actually
Some also say when they hear this when I talk this way, "Well,
the value is such a fundamental. Not only is it of practical value,
but it's so deeply imbedded that I'm looking at a value
change which is utterly improbable in our society."
Well, I guess my response is I'm old enough to remember the
beginnings of a civil rights movement which radically changed a
lot of views on race; a feminist movement which changed a lot of
views in the way we should live with women; and, finally, an environmental
movement which changed the way we should think about the environment.
All of those have their problems, difficulties. None of them have
achieved all of their goals, a lot of competition.
But the point is we took things that you would have imagined 100
years ago could never have been changed because they were so deeply
embedded. And we did change them.
So what I guess I'm looking for is a new model of what health
care should be. And I will give you my own sketch of that. This
paper, if you'll take a quick look at that, is called "Competing
Models of Medicine." I will just run through it rapidly.
I don't think I need to spell these things out.
Model one is the modern, what I call the particularly American
model of scientific medicine. Its goal, basic goal, aims for unlimited
scientific progress and technological innovation, regardless of
their long-term aggregate cost and community impact.
There are no defined finite goals. The aim seems to be a conquest
of all disease, one disease at a time; indefinite increase in human
life expectancy; relief of all suffering, physical and mental; satisfaction
of all desires that might be achieved through medical means.
Medical progress and technological innovation are allowed to set
medical goals and to change and redefine those goals, outcomes,
considerable medical progress, which has benefitted all of us, and
the creation of a massive medical industrial complex.
This model has a powerful bias toward cure, rather than care;
acute, rather than chronic, disease; length of life, rather than
quality of life; individual benefit, rather than population benefit;
technological interventions, rather than health promotion, disease,
and disease prevention; subspecialty medicine, rather than primary
and family care; and increased medicalization of life and social
The net result is we get unsustainable economic pressure on all
health care systems due to aging societies and the increased medical
need they bring with them; expensive technological innovations that
bring usually marginal population health benefits only; and an increased
public demand as a result of increasing an often unrealistic public
expectation and technological hype with just enough success thrown
in to keep everybody enthused.
I think the major threat to even the possibility of having universal
and equitable health care as a result of this growing number of
uninsured I think in the countries that have universal health care
a real threat to their hanging onto it.
Of course, we have a turn to the market by many who are looking
to turn to create two parallel systems of public and private as
a way of relieving economic pressure on the public system, which
often results by most evidence, I think, in a widening gap between
the public and the private with the public system losing, expanded
out-of-pocket costs for patients, and economic incentives for physicians
to lower the quality of care.
What have been the dominant reform efforts with this model? No
interest in changing the underlying model of progress, innovation,
which remains unquestioned, the use of evidence-based medicine,
striving for greater efficiency in health care, economic and market
incentives to hold down costs and utilization of medical technologies
and medical facilities, improvement of managed care or other forms
of group practice. And so I'll leave that, the Balanced Budget
Act. That was an earlier development.
So here's my model, my alternative model that I call sustainable
medicine. And that is a medicine that is affordable for individuals
and economically viable for societies, equitable in the sense that
it's accessible to all and that while there would no doubt be
tiers of care, that the gap between them would not be a damaging
or offensive one.
By "sustainable," I mean economically and socially sustainable
over the long run, which, in effect, means that some time or other,
we are going to have to become satisfied with a kind of plateau,
where we will more or less level out.
We can't continue in this or any other country increasing
the cost of health care well beyond the general rate of inflation,
which means logically, it seems to me, that we're going to have
to plateau on our spending.
This is a medicine to be sustained. For this to work, death has
to be accepted as an inevitable and necessary part of the human
condition; some degree of suffering is inevitable; that there is
the reality of human dependency at some time in life; that there
is a need for rationing and a dampening of public expectations;
caring becomes as important as curing; — and I am sure you
remember Joanne this morning talked about the great problem we are
facing with long-term care and what is going to happen to the large
numbers of people in the years ahead who don't get it —
the need to set priorities in the provision of health care; understanding
old age is a time of decline and limitation, open to amelioration
but not elimination; and, finally, a great emphasis on public health
programs, the importance of socioeconomic status, the availability
of good primary care as the main determinants of the health of populations.
In short, a medicine that sets finite goals for itself, being
primarily a reduction of premature death, death itself is not the
enemy, only prematurely, big footnote, — of course, you can
squabble about what that means — and that the mission of medicine
is set within the context of other social needs, not assuming a
more important or necessarily higher status.
The outcome I would hope if we could come around to that is a
medicine that is economically sustainable. That is, there is more
critical thought about what counts as genuinely beneficial progress,
what do we really need as human beings, what can we afford to pay
for it, what we really need, that there will be rationing at the
margins, but basically there will be accessibility for all, and
that medicine and health care are understood to exist for the benefit
of patients and not as a source of income or financial gains beyond
modest levels and balancing its concerns for the acutely ill and
the chronically ill.
The dominant reform efforts would be to change public perception
and understanding of medicine from one that is inherently progress-driven
and infinitely expansive in its aspiration to a model of a sustainable,
more modest, and limited medicine; change the biomedical research
priority in the direction of seeking a more affordable medicine,
especially technologically, aiming for a compression of morbidity,
rather than an increased life expectancy; establishing of priority
systems for health care needs, and coming up, in particular, with
a more demanding standard of what counts as needs than I think de
facto we have now; and, finally, educate professionals and the public
to understand that equitable medicine will not be possible unless
it is a sustainable medicine. Sharply rising costs will eventually
push the poor out of the system, and it will no longer be a viable
In short, I believe that if one wants to make a good argument
for universal health care, as I think can be made, one at the same
time says it can only be done within the context of finite goals,
finite ends, and the setting of limits.
CHAIRMAN KASS: Thank you very much.
PROF. SANDEL: Dan, I liked this very much. I'm ready
to sign up for your proposal. I have two questions. First, can
you give us an example just to make things a little harder for those
of us who are taking up your banner? What would be the biggest
area of current medical spending that you would on your proposal
cut back as not being in line with the philosophy of medicine that
you had proposed?
DR. CALLAHAN: Well, I suppose I think John Wennberg very
nicely touched on it this morning excessive preoccupation with acute
care hospital medicine and trying to persuade people and the evidence
seems to have accepted it that more is not better. I think we really
believe more is better.
So it seems to me the acute care sector is the most costly sector.
The acute care sector is where most of the emphasis of the new technological
developments come in.
I guess I would also —
PROF. SANDEL: How would you try to talk people out of
DR. CALLAHAN: I would start with the Medicare system.
And just as now drug companies have to prove safety and efficacy
to have drugs released. I would say that the companies should also
have to release economic impact statements, what they think their
product will do to health care costs, even though a lot of it would
necessarily be speculative, but they should do it.
What we get now is basically the market develops a lot of expensive
technologies, throws them out the window, and says, "Okay.
You people use them. I hope you can find a way to pay for them,"
just as in the old environmental days, people just threw their trash
in the river and said, "Well, why not throw it?"
And I think that is what the market system does basically with
technology. And it knows they'll sell. It pushes some people
like the doctors. There is profit to be made.
So I would really work on coming up with much more. I would also
work much more rigorous standards of what counts as a benefit.
For instance, in vitro fertilization is a wonderful example because
I think the best clinics maybe get a 25 percent success rate. People
can go through 3 or 4 cycles at 10,000 bucks.
Now, by any standards, that is a pretty damn poor outcome for
an awful lot of money. Politically, though, it's an item that
you can't go near because people do want babies desperately.
But when the debate comes up about whether it should be covered,
I would be prone to say no.
A reporter recently called me about an interesting case, whether
Medicare, the new Medicare pharmaceutical bill, should cover Viagra.
It seemed to me no.
Now, it may be true — I'm sure it is true medically
— that some people have erectile problems basically for medical
reasons, but maybe you can tease those out but just to pay for it
on the grounds that a lot of people want it.
There is a beautiful case of, quote, "need." Now, do
I at 75 need sex or want it? That's a fuzzy kind of question
there. But we don't talk about that very much.
And do I need expensive surgery, which may or may not benefit
me? I might say I need it if I want to leave. I might say I need
it, even if the odds are very low. On the other hand, societally
we may say we are not going to pay for low odds anymore.
I think, particularly with the elderly, this is where it gets
most radical, I suppose, I would say, "Look, beyond 80.85 the
standards of acute care medicine and applied technology should be
exceedingly high, namely there's got to be the promise of a
really good life expectancy thereafter, at least as good as if you
didn't have the illness in the first place."
PROF. SANDEL: Yes, right.
DR. CALLAHAN: And that would save us a fair amount of
money, I think.
PROF. SANDEL: I like all of that very much. I have a
broader question, but maybe I will save it until later.
DR. CALLAHAN: Okay.
DR. FOSTER: Let me follow up on a question.
DR. CALLAHAN: Yes.
DR. FOSTER: So I gather that one of the things
that you would anticipate doing would be to limit big pharma from
developing these drugs that come along.
DR. CALLAHAN: Absolutely.
DR. FOSTER: Now, what do you think the impact would
be on the American economy? I know nothing about this, but if you
read the newspapers, Wall Street Journal, what happens to the big
pharma determines hugely what the outlook is.
And so how far are you going to take it back, just to the generic
drugs? I mean, if you are talking about this, you have to be realistic
about what it is going to do from all sectors.
DR. CALLAHAN: Well, I guess so. But at the same time,
it seems to me that is a terrible trap. One of the things I find
strikingly different about the American health care system from
the European health care systems is that we talk about all of the
side benefits of health care. I don't find the Europeans saying,
"We like our hospitals because you get a lot of jobs."
We do that in this country. And it seems to me that's very
I think the net result is that it would no doubt hurt the pharmaceutical
industry if we force them to, say, use price controls, as they do
in Europe, we force them to cut back on their research.
But I am not sure that it would make any enormous difference in
future health if we did so. We might lose some jobs, but we are
a thriving economy. Sectors come and go in our society all of the
time. We find new things to put in their place.
So I would say sure, it will have some bad effect, but we still
will want drugs and we still will want some progress. We will just
hold them, I would say, to higher standards than we do now on economic
DR. FOSTER: Well, you could stop all the billions
of advertising on television a —
DR. CALLAHAN: That would sure help. I mean, actually,
direct consumer advertising turns out to be enormously successful.
DR. FOSTER: Let me make one other comment. I almost
never talk at these meetings. So I'm talking a lot here.
It seems to be counterproductive to say in some sense that technology,
whether it's biotechnology or space technology or whatever,
is something that needs to be constrained, instead of saying that
this is one of the glories of being humans, whether you're writing
music like Mozart or — you know, Richard Feynman said that
when he talked about the miracle of the universe and he waxed so
eloquently about it that he said it's almost like a religious
experience, the late Richard Feynman, the nobel laureate.
But he says — and one of the things that is amazing is this
atom, this human, this atom, who wonders and wonders why he wonders
but is driven to wonder. I find it very —
DR. CALLAHAN: I guess I would make a basic distinction
between what is often called basic theoretical research and applied
I would love to see a couple of billion dollars taken from the
NIH and put into astronomy, say, because I think that is fascinating
stuff. We're not going to get a lot of money out of doing that,
but we are going to understand things.
I would keep supporting basic biological research. To me, the
problem is the translation of that research into saleable products
is where the problem doesn't come from doing the research and
gaining knowledge per se. The problem is when we try to turn that
research into money and cures that then it seems to me one has to
set the limit on the innovation.
I think it is wonderful to have developed, you know, the internal
combustion engine and understanding how all of that works, but we
have an enormous automobile problem in this country. We don't
have any contraceptive for it either.
DR. FOSTER: Well, I may have misunderstood. It
sounded like to me that you wanted to limit human ingenuity and
research and so forth in the interest of —
DR. CALLAHAN: I would limit a lot of the technological
innovation but not the basic drive for understanding.
CHAIRMAN KASS: Jim Wilson?
DR. WILSON: Your proposal is one that I do not sufficiently
understand. And, therefore, I cannot share Michael Sandel's
enthusiasm for it, but I want to try to gather more information
because my enthusiasms are often slowly aroused but when aroused
Have you or has anyone who thinks as you do tried to work out
the effect on medical costs, the goal now being to cap them at the
rate of inflation, of doing such things as restricting acute care
facilities or limiting the availability of certain technologies
for people over 80 or 85 years of age or other things you have talked
These are ideas that are eminently worth discussing, but I have
no idea whether they will solve the problem.
DR. CALLAHAN: I must say that I don't either, but
I only propose them because I don't have any idea whether any
of the management changes will solve the problem either. They are
at least as difficult to put lots of figures on.
I suppose the point is what I need is for somebody who is in the
business of constructing health care systems and running costs to
take my idea seriously and use their skills to figure it out.
I must say I don't know how you figure — knowing in
the first place it is enormously difficult to project health care
costs and prices, you know, much over five or ten years. It's
a real crap shoot doing this. I would agree mine is exceedingly
difficult to do this. But, on the other hand, it seems to me let's
start the work and see if we can figure that out.
DR. WILSON: Well, the point I was making is that this
work was started 25 or 30 years ago, when people in this country
began talking about finding restrictions and when various states
began setting up commissions to discuss, not with any action yet
worth speaking of, about how you restrain the growth in health care
And so if in the last two and a half decades, nobody has figured
out how to control costs, why are you optimistic that somebody will
think of it now?
DR. CALLAHAN: Because I am going at a different level
of the problem that has been discussed because everybody took for
granted that we needed to constantly be improving everything and
having the technology and the innovation.
This is the bottom of my chart. That is the part that hasn't
been examined. The top has been examined like crazy. And we're
still fiddling with that, but the bottom has not.
I want to introduce another angle into this discussion.
DR. WILSON: That angle has been introduced. People have
long said that the bottom end of the chart is unmanageable, but
nobody has come up with a plan that would contain it.
Now, such plans are available, single-payer, universal health
insurance plans of the sort you have Canada or England or Germany.
That is one set of strategies. It would be politically difficult,
but not impossible, to do that in this country.
Other strategies are to constrain the availability of technology.
Another strategy is to constrain the availability of acute care
What I am suggesting is that you are not suggesting anything new.
You are leaving the argument where it was 25 years ago.
DR. CALLAHAN: No. You tell me. I don't remember
anybody in the past saying, "Let's rethink the idea of
progress itself." Limiting the availability of technologies
or trying to control the number of hospital beds is not to confront
the problem of progress. It's to confront the problem of how
you manage your health care system.
I want to take up the value of progress, which is the one that
seems to me to go unquestioned. What you are talking about are
various strategies to deal with costs, which touch on it, but they
don't confront it very directly. And, as many people said to
me, the notion of where we could constrain progress here, that's
insane. That's stupid anyway.
CHAIRMAN KASS: I'm sorry. Michael, do you —
PROF. SANDEL: I wondered if I could just help from another
angle in answer to Jim's question. If you tell them you want
to be against progress, you're not going to win his vote, I
But, as I understand this proposal here, what is distinctive and
what is radical about it is I guess it is sort of at this level
or side which you call ideology and culture, which isn't only
What you are saying is — do I have this right? — you
want to change the culture and the ethic that lead us to consider
— that causes health to loom so large an unquestioned good
that it has a kind of endlessness, endless in the sense that we
don't deliberate about what the point or the purpose of health
is. And so it's an unbounded goal or aim because we don't
ever reflect on what a good life consists in as a way of delimiting
what counts as health.
DR. CALLAHAN: Right, yes.
PROF. SANDEL: Do I have that right?
DR. CALLAHAN: I think that is absolutely right. And one
thing, again, I find striking in Europe — one thing I ask
people a lot, "How much attention is there paid in the media
to issues of health, technology, and medicine?" It's strikingly
much less. It varies from country to country, but when I mention,
say, The New York Times has five or six reporters who do nothing
but report on health care and stuff gets on the first page, this
is much less the case.
There does not seem to be a kind of obsession with health and
health care that there is here. People like good health, but as
somebody from the Czech Republic said to me a few years ago, "Let's
talk about end-of-life care," and the answer was, "Well,
people get old and die. What's the problem? Why do you Americans
fret so much about this?"
I must say, "Well, okay. This is a different culture."
Now, that —
DR. FOSTER: That's not new for you because
a long time ago you constructed a system of contrast, which was,
I think you called it, the power/plasticity model, as opposed to
the sacral/symbiotic model that —
DR. CALLAHAN: You really go back a long way.
DR. FOSTER: Well, I remember things.
DR. CALLAHAN: I had forgotten that.
DR. FOSTER: I remember things, yes.
DR. CALLAHAN: But it sounds good.
DR. FOSTER: So his idea in the power/plasticity
model was that because we can keep people alive a long time we ought
to do it, while in the sacral/symbiotic model (which he preferred)
we accept death as natural, not always to be fought. So you have
been thinking about that a long time.
On the other hand, I still remember Malcolm Muggeridge's famous
statement a few years ago when the U.K. system decided that above
the age of 65, you would not be resuscitated. So it had NTBR (Not
To Be Resuscitated) on your little card there.
When he saw that, he didn't know exactly what that was. And
when we found out it meant that, although he was a vigorous 65,
that if he should have sudden death, that he was not to be resuscitated.
So there is sort of built into this — I don't know whether
85 is a year or what, but most people, you know, still would like
to keep — if their health is good, they actually —
DR. CALLAHAN: What Great Britain did in the '50s and
'60s was there were informal limits, particularly on dialysis.
DR. FOSTER: They had no dialysis. Thirty-five
hundred people a year died because they didn't —
DR. CALLAHAN: But the point is it was never official policy.
It was done by a sort of practice, and it was covered up by calling
it it wasn't medically indicated if you needed dialysis and
the like. But eventually they changed that because of public pressure.
I guess the point is it seems to me that was the same with medicine.
You're going to have to make some hard and nasty choices somewhere
or other. I mean, to me what is going to happen?
We're soon going to get an implantable artificial heart.
It's going to be very effective probably in saving a lot of
lives of people over the age or 85 or 90. It's probably going
to cost a couple of hundred thousand dollars to implant, $25,000
a year to maintain.
Ought we do that? If we don't do it, they're going to
die. Should we do it? And where do we stop this? On and on and
on, it seems to me.
I guess I would take a view I sort of still believe in a kind
of natural life cycle, that it's okay to get old, we don't
have to fight death at the age of 95 with heart transplants or open
Now, you might say to me, "Well, you haven't been tested.
Let's see what happens." Well, we'll see what that
time comes. But I can't imagine having a health care system
that is eventually affordable in the long run without saying there
are certain things we simply cannot afford to do because if we do
them, we're going to have to take some money from other areas
of society that are very well.
I live in New York City. If you need a heart transplant and at
least if you can get the organ, the government will pay for it in
fancy hospitals with highly paid people. Two blocks away, we've
got the high schools that are lousy, overcrowded, buildings falling
down. Then you have to say, "Well, is this the right way to
spend money in a society?" I'd like to see that kind of
An issue that doesn't get much discussed is how we want to
balance the different sectors, but I think in the end, any limits
you suggest, somebody is going to say, "Well, it's murder.
It's killing. Isn't that awful?"
But, on the other hand, if you have increasing health care costs,
one effect of the increased health care costs is companies are cutting
back on their benefits. The number of companies that provide health
care benefits are going down or they're cutting it at family
members. You really get a lot of lousy fallout from these costs.
DR. FOSTER: I'm not against the sacral —
DR. CALLAHAN: Okay.
DR. FOSTER: — at all. I think it's a
wonderful model. It's just the question is, where is premature
death? I mean, if you were to die today, you say, "Well, okay.
I've reached beyond the three score and ten, but I still think
I have something to offer." And as a consequence, I would
think it might be premature if we had something that we could save
their life and so forth.
DR. CALLAHAN: Well, I would say fine as long as I feel
I'm not taking resources from the young taxpayers who would
be paying my Medicare bills and could not bear this burden without
hurting their own lives. That would be my standard.
CHAIRMAN KASS: Dr. Wennberg?
DR. WENNBERG: Sorry to join in, but since I'm down
in level 1, I wanted to have a chance to —
DR. CALLAHAN: Thank you. That's —
DR. WENNBERG: I think that, Dan, it seems to me that
the level 5 statements here are confusing to me because I think
that you and I have a different opinion about when progress has
happened in medicine.
So that what I would like to see at level 5 is a skepticism about
manifest efficacy; in other words, the belief that if it happens,
it's good for you because it's medical care so that and
we ought to do that both with our physicians to make them more skeptical
about theories and more willing to investigate them because I am
quite certain that things that you mentioned about being medical
progress are probably going to be very problematic when you look
carefully into who gets it and what the outcomes are.
We're actually doing some work right now with bare metal stents
versus the drug.eluting stents. And it's not as good as it
sounds maybe. We don't know yet.
The point is that carefully looking at technology in a post.marketing
surveillance sense creates the information that essentially would
I mean, Vioxx was hugely skeptical, skeptic-producing. And so
a more sophisticated attitude towards technology and a more sophisticated
attitude towards progress — I mean, I think progress is great.
We just don't see too much of it. And your list is kind of
progress, but it isn't really.
And so becoming more sophisticated in terms of our demands for
evaluation and assessment and, yes, cost.benefit analysis and then
taking that information into a much more public debate would maybe
get us to where you want to go because I think you want rationality.
I'm not sure you need to do that through rationing at this point,
but maybe you do.
To me, there is an awful lot of excess capacity in that acute
sector. And there is a lot of surgery being done to people who
don't want it. And you want to take that into account and fix
that problem along with the societal problems because the fixes
for those two problems actually involve significant drag in terms
of the current perceptions of what goes on. The role of the patient
in discretionary surgery, how to act on that, how to finance that,
that is a big deal, and also how to deal with that excess capacity
problem in the acute sector, which I think most people recognize
It's not a big mystery anymore, but it is a question about
how do we begin to deal with "You can close anybody else's
hospital but not mine" or "You can put pressure on this"?
Those are pragmatic political questions. Getting that skepticism
into place I think would be more likely than having a debate about
whether the enlightenment was really worthwhile or we're believers
in infinite progress when, in fact, there's not —
DR. CALLAHAN: Well, let me give you sort of one question
back to you. It's very possible that everything you suggest
will forestall the day of reckoning where we find we have done all
of that and here we're still — that's very possible,
that day. And then maybe the day will never come, but my guess
is at some point in the long run, what I am saying will be true.
It will not be possible to keep indefinitely trying to keep people
alive and by virtue of evidence-based medicine finding a way to
pay for it.
I guess, secondly, with evidence-based medicine, I am struck by
a point that does not seem to get touched on very much. You have
pointed out, in some hospitals, under-treatment. We're finding
out that only like — I forgot the exact figure — 50
percent of people who should be taking high blood pressure are taking
them, only 50 percent of the people being treated for cholesterol.
This is evidence-based medicine telling us we should be spending
more on things.
I think evidence-based medicine turns up as many things that we
should increase our spending on as on things that we can cut back
on because they're not efficacious. So I see that as a two.edged
I guess I am struck by the fact that when I look at the European
systems, they're having trouble, too, though they actually do
a lot better on many of the things you've mentioned than we
do. But, even so, they are straining.
But let me ask you the short term versus long term. Do you think
what you are suggesting will be work indefinitely long into the
future to keep us from having to rethink progress?
DR. WENNBERG: Well, I guess I would say I don't know
because I can't predict the future, but I would say that the
basic scientists feel they can save us from ourselves by coming
up with cost-effective treatments that require very little of what
Lew Thomas called intermediate technology. So it's probably
just as well to bet on that as it is on the idea that something
will come along.
They sure haven't succeeded in the history of NIH in doing
DR. CALLAHAN: They also haven't succeeded in evaluating
what they're doing.
CHAIRMAN KASS: Let's collect a couple of questions.
Then Dan can take them together unless there's a kind of dialectic
development in which people can jump in.
Robby George has been waiting and then Frank.
PROF. GEORGE: Thanks, Leon.
Dan, I think I understand, although if Jim Wilson says he doesn't
quite understand, then I'm sure I don't understand. But
even understanding as I think I do, I can't quite share Michael
Sandel's enthusiasm. I think I agree with the sentences beginning
with even numbers and disagree with the sentences beginning with
odd numbers, but there is much wisdom there.
Two questions. First of all, the point that you made about the
Europeans' comparative advantage over us on the question of
commitment to solidarity, we can quarrel after the session about
whether that is in the end true.
I was wondering what you were using as a measure. Was the measure
of that simply the question of the social provision or the governmental
provision of social services or would you be prepared to defend
when we do argue about this?
Would you be prepared to defend that in more general terms, the
Europeans when it comes to charitable giving and the range of other
things that we might factor into any assessment of comparative commitment
to solidarity, that the Europeans would still be dramatically ahead
DR. CALLAHAN: Well, I would say certainly in the area
of health care, the dramatic — they look upon health care
as a simple moral proposition. All of us are equally subject to
illness and suffering, and we should support each other in that
mutual thread. That's the notion of solidarity. We are humans
who are in this common situation.
In fact, in this country, we already have a common notion of solidarity.
We have it in solidarity in fire departments. Everybody agrees
there should be basic fire departments. You may buy extra, but
we are all going to get fire protection, regardless of whether you
live in a brick house or balsa wood house.
We also believe in common police protection. Again, it's
a notion of solidarity. They put health care in the same system
in the same kind of context. This is that we all share a problem
and, therefore, we should pay and support each other for particularly
health care, which is very expensive.
So I think it's interesting. It really goes back to Leo XIII
and papal teaching, interestingly enough. That's the historical
origin of that. It's a very communitarian notion of what it
is to live together in a society.
They do believe that, of course, a heavy dependence on government.
They don't have the nasty view of government that we do in this
country. Unfortunately, you know, they happen to get better health
outcomes as the bottom line for all of these values.
PROF. GEORGE: But there could be a range of reasons
for not going for the kind of health care system that you have that
don't have to do with the rejection of solidarity as a principle.
You could believe that it wouldn't work very well, it would
be counterproductive. There's just a whole wide range of —
DR. CALLAHAN: The only alternative to a government system
is the market. And the market is not big on solidarity. The market
is big on satisfying preferences and self.interest. It is not interested
PROF. GEORGE: But you wouldn't want to jump
to the conclusion that every time we go for a market solution over
a governmental provision solution, that must reflect a lack of a
commitment to solidarity. That would be —
DR. CALLAHAN: Well, no. Actually, I like what the Europeans
are doing because the Europeans hang on very much to solidarity,
but they do a lot of market experimentation. But they say our core
value is that we are going to continue providing access.
We are going to see if the market can help us control the costs
a little better, get a little higher quality. That seems to me
a very good use of the market, but their basic commitment is we
are going to make sure everybody has pretty good access.
But we're going to try to use the market to improve the system.
So it's the use of the market within the context of universal
PROF. GEORGE: Okay. Well, we can have one of our
arguments about this off record.
The second question I had was something that you said that I found
very interesting and provocative, so much so that I wonder if it
was a slip of the tongue or if I misunderstood you.
Down in level 5, Dan, when you were in ideology and culture, you
said or I thought you said that both sides love the market, both
the left and the right love the market. Did you mean that or were
you saying that both the left and the right love progress?
DR. CALLAHAN: No. I'm sorry. Both the left and right
love progress for somewhat different reasons, though.
PROF. GEORGE: Yes. Okay. I wondered whether you
had in mind the British Labor Party and the New Zealand Labor.
DR. CALLAHAN: No, no.
PROF. GEORGE: No? Okay.
DR. CALLAHAN: No, no.
PROF. GEORGE: So it was just a slip of the tongue?
DR. CALLAHAN: Yes.
CHAIRMAN KASS: Frank?
PROF. FUKUYAMA: Well, Dan, I'm quite sympathetic to
the analysis in the following sense. It seems to me there has been
this unacknowledged down side to technological progress that was
made very clear.
I missed Joanne Lynn this morning, but I heard her when she briefed
the staff of the Council. From that, it just seemed to me very
clear that the cumulative effect of a couple of generations of biomedical
progress was to allow people that would have died relatively quickly
and at low cost to the rest of society from a heart attack, you
know, allow them to spend ten years in slow degeneration at extremely
large costs to society.
You know, this was a big elephant in the room that nobody was
willing to acknowledge that, you know, perhaps there actually not
only hadn't been progress but we in a certain sense left ourselves
But it does seem to me that this proposal, even if you acknowledge
that, is awfully hard to implement and particularly awfully hard
to implement in the United States because you really do have to
abolish the market, I mean, completely.
If you allow the market to operate, there are so many people out
there that will want these services that they will simply get them
from people that are perfectly willing to provide it. So you have
to go to a state.run single-payer system that is actually much more
draconian than any of the ones that exist in Europe now.
And all of those European systems are, as you suggested, under
tremendous pressure to liberalize their criteria for rationing medicine
because their publics really want this stuff.
The other thing is that I am not sure that this is the right place
to freeze progress because this is the wrong plateau. I mean, if
we're really on this plateau where everybody is going to require
ten years of dependent care, that's not such a great place to
And so I guess it just seems to me that all of the political pressures
are pushing in a very different direction, particularly here in
the U.S. I just don't see the political feasibility of this.
DR. CALLAHAN: Well, it's very interesting. There
seem to be different views of where things are going. There is
one view of some recent studies published in Health Affairs to say
that a lot of people are getting suspicious of going more in a market
direction. I was thinking maybe we're going to have to go back
to government. And, actually, the study I mentioned by the Medicare/Medicaid
department said we're going to go up to around 50 percent of
government spending anyway.
I think your interesting point about the slope of progress was
about all this. I guess the question is, it seemed to me, at least
for a long time, that there has been excessive optimism about being
able to overcome the diseases of aging.
When we got started, Leon will remember Lewis Thomas, I think
somewhere around the mid 1970s, a great medical writer, said, "Well,
in my generation, we have seen infectious disease overcome. Before
I die, we will also see the chronic and degenerative diseases of
aging overcome as well." Well, he died of cancer some 25 years
Things are getting a lot better, but the point is, I think, as
Joanne showed very nicely, if there are statistics, we are pushing
disability back to a later stage of life, not getting rid of it.
To me, I find it a tragic dilemma in a funny way that it would
have been better if I had died at 65 from a heart attack than now
die at 85 from chronic congestive heart disease, which is a lot
lousier. It's slow, and you can't breathe and drags on
and on. And then if you're around a little longer, you're
probably going to get demented, too. Is this progress?
The point is we're not doing terribly well, it seems to me,
in dealing with these diseases, despite the optimism. So I don't
know where to stop. It might be that if we keep going, we could
make things worse, as we have done in the past. We have made it
worse, not better, in some ways.
CHAIRMAN KASS: Gil, Peter, Janet, Paul McHugh, and myself.
Then we'll probably be at the end.
PROF. MEILAENDER: Dan, first, insofar as what you're
really after is a deep cultural shift, I have to say that I think
there are other institutions to which you need to devote your attention
if you want to accomplish that. We don't get that by writing
I just found myself wondering, what if we did the same sort of
analysis somewhere else? What I mean is, there would be another
way to get the money for those high schools that are so impoverished
and give such lousy education.
Sort of closer to home, what if we asked similar questions to
the kind you ask about the higher education system in this country?
Couldn't we do all the same sorts of questions? How do we decide
whether places are permitted to create new programs and hire new
faculty? How many colleges in the country in recent years are adding
programs in meteorology and communications so that we're going
to be a nation of weather reporters finally?
You can hardly go on a college campus where there is not a new
science building going up right now. Colleges compete to advertise
how well.wired they are, why didn't we freeze that 25 years
ago? Were our students learning more now than when they browsed
the journals in the library? Should we increase teaching, double
teaching loads, say, and cut back —
DR. CALLAHAN: I know the answer to that one.
PROF. MEILAENDER: — cut back on leave policies?
I mean, it's a whole similar range of questions. It's the
same kind of analysis. It's not clear that we're better
off because of our commitment to sort of endless what we consider
progress in the academy. And I don't think that being badly
educated is any better than being unhealthy.
It just seemed to me that the kind of analysis you're doing
could apply in all sorts of —
DR. CALLAHAN: Well, I totally agree. As a matter of fact,
though I don't teach and have never taught in my whole career
and didn't want to teach and didn't want to be in a university,
I subscribe to the Chronicle of Higher Education if only to see
what is going on.
I think the critique is just absolutely of all of the major institutions,
all need this kind of critique. They will take a different form
because they have different sorts of problems, but nothing I am
saying about what we need to do in health care is meant to imply
we shouldn't do it everywhere else that seems to need it also.
PROF. MEILAENDER: I understand that, but what I
am suggesting is that, even though you can find all sorts of absurdities
and I have actually named a few of them that I regard as that, we
don't, in fact, think that the way to solve that problem in
the area of education is a way that would be analogous to what you
are proposing with respect to health care.
Now, maybe you think it would work, but I don't think —
DR. CALLAHAN: Well, I guess I would like to see universities
— I mean, you are mentioning they are all putting up new science
buildings. I mean, they're not putting up big new philosophy
departments. That's for sure.
And it seems to me that everyone might well ask, is that what
this society needs? They're putting them up because there's
money in science. There's not money in philosophy in the English
literature and things of that sort. But everyone can ask, what
do we need from higher education? Do we need more science buildings
or more of a lot of other things it seems to me a lot of analogous
sort of question.
What are the proper goals of higher education: to turn workers'
jobs to make money for the university, et cetera, et cetera, et
cetera, or what?
PROF. MEILAENDER: That's fine. You're
a man of perfect consistency here. It just seems that buried somewhere
there is an enormous confidence about our ability in macro ways
to figure out what actually constitutes progress and would be a
DR. CALLAHAN: Well, I think it's terribly hard. I
would like to see it discussed at least, though. I mean, it's
interesting. There's been a slate of books and articles that
being richer doesn't make you happier. Getting all you want
doesn't make you happier. A lot of progress creates as many
problems as it solves.
So I think there's sort of an interest in looking at all of
this stuff all over the place, particularly the notion "Gee,
we are a rich and powerful nation. Why are we so unhappy?"
That's a theme one can find around these days.
So do we really have a disagreement here? I'm saying sure,
it's very hard, but so what?
PROF. SANDEL: If you don't, Gil's about to make
a brief for unhappiness.
PROF. MEILAENDER: No. I just think that at the
bottom, you are a religious thinker. That's, of course, not
a criticism when I say it, but that's the kind of analysis that
you're actually providing and —
DR. CALLAHAN: No. I'm a liberal who would like to
see liberals deal with the kind of questions that religion deals
with in a better way.
PROF. MEILAENDER: The malady that you discern requires
a solution that goes deeper than any you can offer.
DR. CALLAHAN: I find the enthusiasts for technological
medical progress seem to be as deeply embedded in religious communities
as nonreligious. I don't see that makes a hell of a lot of
I mean, I know a lot of people who would say what I am doing is
proposing that we kill people. Somebody said, "Callahan, this
is social euthanasia. There are people who are going to die if
they listen to you." Well —
PROF. MEILAENDER: You want to teach us to think
differently about our desires.
DR. CALLAHAN: That's right.
PROF. MEILAENDER: Okay. And what I said is that
is an illness that goes deeper than any solution you've offered
can deal with.
DR. CALLAHAN: Well, I agree it probably is.
PROF. SANDEL: Yes. Embrace that, Dan. Don't shrink
CHAIRMAN KASS: Your solution is not a religious one.
DR. CALLAHAN: I'll fill in all the details of how
to do it.
CHAIRMAN KASS: Let's go. Peter Lawler, Janet, Paul.
DR. LAWLER: I agree with what has been said. What
you have here is a broad side against the American way of life.
So I agree on your list of powerful biases you lay out here are
powerful biases, but I see you have seven of them.
You must be some kind of Straussian because the one in the middle,
number 4, is individual, rather than population, benefit. That
is, we consent to government as individuals. I can't be used
for the population. I'm not a bee or an ant.
Now, if that's the case, I think you might ignore the noble
side of this way of thinking about things, which can be stated along
these lines: intrinsic dignity of the individual or something like
And the other great movements you talked about, like the women's
movement, the civil rights movement, and so forth, were on behalf
of individuals, lifting them up or out of artificial constraints.
And maybe an unsustainable side, I have to admit, of a country
devoted to individuals, that side is unlimited technological progress
because technological progress is clearly a benefit to individuals.
So it seems to me there is also something connected with allowing
technological progress to be limited on the side of equity. For
example, isn't there something noble about the American impulse
we have talked about? As soon as dialysis is available, the American
impulse is to say, "Everyone gets it." That may not be
sustainable, but that is still noble in my opinion.
There may be something bad about the fact that not everyone is
covered by insurance, I have to admit, but the consequence of saying
IVF is not covered by insurance, I'm not even for IVF. Nonetheless,
rich people will still get it. All you're doing is denying
IVF to the poor. All you'd be doing is denying dialysis to
the poor. Rich people will still get it somehow and the same thing
with Viagra and all the other things that were mentioned.
So my criticism or what I would like to hear you talk about is
aren't you kind of setting up a straw man here by not talking
about the noble side of a country devoted to the individual?
DR. CALLAHAN: Well, I guess it's a matter of how much
is enough, how far do we want individualism to go? I think I'm
properly — someone characterized me as I'm a communitarian.
That is to say, my first question is what is for the benefit of
And I'm a kind of Aristotelian. We are not isolated individuals.
We live in a web of other individuals. And my individual good or
bad is going to impinge or affect other individuals.
There are plenty of wonderful things in the individual. In fact,
it's not hard to list them, but I think have we reached the
saturation point. I think it's wonderful that people have automobiles,
but have we reached the saturation point of how many automobiles
we can tolerate on the roads in our — I live where everybody
spends hours in traffic jams all the time.
I say all right. It's wonderful to have this individual right,
but collectively whether it's doing us much good begins to be
open to question.
DR. LAWLER: So you're for individual rights
and all —
DR. CALLAHAN: Oh, sure, absolutely.
DR. LAWLER: You're just against the excesses?
DR. CALLAHAN: Absolutely. That's a nice way to put
it. And the question, though, is when do you reach a point of excess?
And how do you know it when you see it or have you been so brainwashed
you'll never know it when you see it.
CHAIRMAN KASS: Janet Rowley, then Paul McHugh?
DR. ROWLEY: Well, contrary to Michael, with whom
I almost always agree, I am very troubled by your presentation today.
And maybe it's because of my close connection with oncology.
We have used the information that has been gained over the last
decades, particularly in understanding the human genome, to make
enormous progress in developing drugs that can be remarkably effective
in treating patients, some patients, with cancer.
For example, patients who have chronic myelogenous leukemia, now
a high proportion of them can be treated and often, if not cured,
at least have very, very long remissions due to Glevec or Amantanib.
There are a number of others of these that are coming down the line
that are going to be very effective.
So saying that we should shut off medical progress now and that
implying that it's only just for doctor self.amusement or scientist
self.amusement that these things are being done I think is a real
distortion of that.
DR. CALLAHAN: I don't think in my outline I talked
about scientific doctor self.amusement? I don't believe I did.
DR. ROWLEY: You don't, but you take medical
progress and say, "Is it really progress?"
DR. CALLAHAN: I don't. I would —
DR. ROWLEY: I think that that is just a dreadful
point of view.
DR. CALLAHAN: Well, I would take your field of oncology
as a wonderful example. I would say with new proposed treatments
with chemotherapy, radiation treatment, that the standards of accepting
them and paying for them should be very high, a short time of life
expectancy would not be good enough to qualify.
I'm not for stopping the research. I'm saying let's
make sure when we begin applying the research, that we are very
demanding in what we will accept as a good outcome. That's
all. That's not to be anti.progress.
DR. ROWLEY: Now, aim for a limited scientific progress.
And where do you decide what progress is okay to pursue? And which
ones should you abandon?
I think this is a really terrible way to look at a very difficult
problem, namely health care costs and their increasing health care
costs and the inappropriate use of some medical services in various
categories of disease.
DR. CALLAHAN: So are you saying we shouldn't have
this discussion at all?
DR. ROWLEY: Well, I think that the point of view
that all of our problems or many of our problems are due to the
hubris of scientists wanting to have studied things —
DR. CALLAHAN: I don't believe —
DR. ROWLEY: — and have progress, regardless
of what the outcome is and regardless of what the cost is, I think
is not the appropriate focus.
DR. CALLAHAN: I didn't say individual scientists.
I said the enterprise.
DR. ROWLEY: But the enterprise — science
only goes forward with individual scientists. This is not something
on high that people are doing. It's the individual that contributes
to the progress. So it is us as individuals that I think —
DR. CALLAHAN: But it has —
DR. ROWLEY: — could be interpreted as being
the focus of this.
DR. CALLAHAN: Well, I think there is a culture. There
is a culture of science, which has once unlimited technological
innovation, which, again, is different from unlimited scientific
DR. ROWLEY: But you lump them together here.
DR. CALLAHAN: No. In answer to one of the other questions,
I separated them. I said they are different enterprises, it seems
CHAIRMAN KASS: Paul?
DR. MCHUGH: Well, thank you very much, Mr. Callahan,
for coming because, as you know, I have been listening to you for
about ten years. At first, I just thought you were perverse. Now
I think you're just out of date.
I agree with Janet and Peter and very rarely again disagree with
Michael. But, look, there are aspects of the things you are saying
that are really quite paternalistic and puritanistic, too, in a
Fortunately, this time we had your paper to study before we came.
I had a good chance to read over it. And although you didn't
present this paper and I'm not going to quite comment about
it, I have to say that I have heard this kind of stuff before, particularly
ignoring the fact that he who defines need makes a political decision
and exercises power over those who depended upon the decision.
Here in America we think that people ought to vote on what we
need and ultimately see how what we want develops out of what is
available to us.
You know, as I was reading your stuff, I kept thinking the ghost
of Beatrice and Sidney Webb was just floating through all of this
with their beliefs that individualism in competition ultimately
leads to anarchy of some sort and the anarchy here of costs. And
it's to be combatted by centralized authority and oversight
committees of experts that will bring social discipline to all of
I just want to ask you whether that is a correct thing. Gil calls
you religious. I think that in various places of the world, where
we are trying to provide care for those who can't afford to
pay for it but ultimately insist, in some way or another, those
who can pay for it do so, is the aim that we are going towards.
And that permits us to be both progressive and developing and optimistic
about the future and presume that we're going to do better than
we're doing now.
We heard from Dr. Wennberg that there is all this excess capacity.
I think we should employ that. Tell me, are these your forebears?
Do you live with Beatrice and Sidney Webb and all of their loves?
DR. CALLAHAN: First of all, my argument at this level
has nothing per se to do with government. First of all, just a
little footnote, for 30 years now, public opinion survey said a
majority of Americans would prefer universal health care in this
country. That's been talked about. Consulting the people and
their view of the needs, I believe that's true, Dr. Wennberg,
that surveys have always supported universal health care.
Secondly, I don't believe in decisions by expert committees.
I believe in public decisions. This is a committee that has got
a few people who are experts in bioethics, but it's got a lot
of other people. That seems to me the right kind of committee.
It seems to me these issues —
DR. MCHUGH: I don't see how these kinds of
things are going to be decided if you don't have certain experts
that are going to tell us all how we should live, what we should
have, what Janet should work on, those kinds of things, and what
should be available to us, whether it be Viagra today, IVF tomorrow,
or something else. It looks to me like you are determining for
us what we should need and we ought to keep those needs under control
DR. CALLAHAN: Well, I'm saying —
DR. MCHUGH: — daddy knows best or —
DR. CALLAHAN: Well, I don't —
DR. MCHUGH: — daddy, not big brother.
DR. CALLAHAN: I think this is a total parody of what I
said. And so I don't think I said any of that in any case.
You see, this is the problem about talking about progress. Everybody
feels terribly threatened. And, by God —
DR. MCHUGH: I'm not threatened. Keep the
psychology out of this. No, no, no.
DR. CALLAHAN: They're going to drag their old dead
horses into the discussion now.
DR. MCHUGH: Listen, I love it when you bring in
psychology to psychologists. You know, every interpretation is
hostile, Mr. Callahan, and I don't have to put up with that
CHAIRMAN KASS: Gentlemen, gentlemen. Let me have a try
and since I think I have had some sympathy for just about everybody
who has spoken here, which means that there is something about the
way in which Dan has presented this that has produced a certain
kind of polarizing reaction.
People are, as I know better than most people, generally responsible
for how they are misunderstood. Nevertheless, we should do our
best I think to try to separate out what has been said here that
is I think worthy of our attention. I will do this partly I think
coming to your aid and also partly, I think, raising some difficulties.
It does seem to me that it is good of Dan to raise the question
about what are the goals, what are the implicit goals, of the way
in which we are proceeding. You can raise that question without
attaching the slogans of are you for or against progress or are
you for or against death or are you for or against the enlightenment.
We have a system which has been operating under certain kinds
of tacit assumptions. It looks as if we are behaving as if we believe
the goals are right. We are not just getting there fast enough.
And the more there is, the better.
Wennberg at least raises the question as to whether more really
is better. And that, of course, raises the question of, what do
you really mean by better and how do you know whether you're
going forward or backward with respect to the goals that you do
And then Dan wants to raise the question about whether or not
these finite, these not defined goals that we have under the modern
particularly American model are reasonable. He lists five goals.
And it's a perfectly reasonable question to ask not of individual
scientists and not even of the scientific establishment but to ask
the society as a culture, are these goals to which we subscribe?
And does it make sense to commit oneself to those goals as if one
had infinite resources and infinite capacities and what it would
mean to commit yourself to those goals, rather than to the goals,
for example, that Janet is frequently reminding us of in the other
discussion, the question of care for children and not only of the
health care of children but I assume their education and their general
nurture and well-being.
So I think that we should welcome, we really should welcome, the
opportunity to have a look at the question of the tacit goals of
this enterprise. That would be one point in Dan's favor.
I am struck, Dan, however, when you come to the Callahan model
of sustainable medicine. The goals that are given are not medical.
The goals are things that have to do with affordable, equitable,
and sustainable. And that is not so much answering the question
of what is medicine really for. That's a question of the system
and whether people are going to be able equally to have access to
it, whether we're all going to continue to pay for it.
Those are important questions all, but there isn't a symmetry
here. The current system you say has as its tacit goals the conquest
of all disease, the indefinite increase of life expectancy, the
relief of suffering, the satisfaction of desires, et cetera, et
cetera. The question is, what is Callahan for?
As a goal of medicine, as opposed to — one of the reasons
why you pick up the vote of Professor Sandel is he is I think, in
a way, less interested in the intrinsic question of the goals of
medicine or at least as much interested in the kinds of questions
of social solidarity, equity, and questions of justice which —
PROF. SANDEL: No, no. The whole point is that they go
CHAIRMAN KASS: Fair enough, but Dan hasn't really
I think sort of put forth the goals of medicine as such, which would
be reasonable goals.
The reason I think that is important to do is because, as has
been said — I mean, Peter Lawler tried to put this in terms
of our attack on segregation and discrimination against women was
in the name of individuals, but I would have said that those are
also attacks against certain kinds of evils that it became increasingly
hard to defend those evils.
Here what you are really going to be mounting a case against is
the desirability of long and healthy life. And there are not a
lot of votes for that. I mean, the change of the culture on this
score is a very different kind of change.
I think you have to try to articulate the kind of goal of medicine
in a culture in which the successes of medicine have not made people
more inclined to disappear. On the contrary, they have led us to
hope and not unreasonably that there will be a cure for Alzheimer's
disease and that, rather than accept these ten years of debilitation,
one should let Dr. Sellcoe and his colleagues loose to look for
a vaccine or whatever it will be.
I mean, it's a kind of endorsement of the question, plea for
a certain articulation of these goals and to do so with the full
recognition that individuals die. And they might be inclined to
die for their country, but I don't think they're going to
be inclined to sort of step aside and forego various kinds of cures
for themselves and their loved ones for the sake of some kind of
abstract notion of sustainability.
DR. CALLAHAN: May I respond to that?
CHAIRMAN KASS: Please. I'm done.
DR. CALLAHAN: First of all, let me respond, as many authors
do. I've addressed all of those issues of specific goals in
another book. My last book on the research imperative ends by specifying
goals. I said a good way of specifying medical goals is to do it
by age group. And I tried to do it briefly for children, adults.
And I have written numerous articles on appropriate medical goals
for the elderly. I've also written in my book False Hopes that
I think the way to go for this healthy life is through the route
of behavior modification, behavior change, public health and prevention
and socioeconomic change because statistically those are the things
that make the greatest difference in the population health, not
So I didn't do it here, but I've done it plenty of other
places. And I have a new book coming out on medicine and the market,
the role of the market in health care. And once again, I take up
the question. My main objection to the market is it doesn't
give a damn about the goals of medicine. That is part of its problem.
Anyway, I have done it.
CHAIRMAN KASS: I'm just struck by the asymmetry in
DR. CALLAHAN: In this presentation, I agree.
CHAIRMAN KASS: In this presentation.
DR. CALLAHAN: There is an asymmetry, but that is just
an oversight. I have played that one out a lot in —
CHAIRMAN KASS: Would you, therefore, be satisfied —
DR. CALLAHAN: But I can't.
CHAIRMAN KASS: Would you be satisfied if one pursued these
goals of medicine in a limited way but that the questions of affordability
and equity and economy were not alleviated?
DR. CALLAHAN: Well, I think we have to do both. I mean,
it seems to me that there is no point in pursuing goals if you can't
afford to pay for the consequences of the pursuit.
Then you have got to live in a — I mean, I think one of
the early debates I got in was arguing with many physicians who
found it absolutely offensive to talk about money in the value of
life at all, basically saying, "Look, you can't put a value
on life. The very notion that you might not pursue certain things
to take account of money is itself a corruption of proper thinking
Well, I think that is simply wrong. You have to do it because
modern contemporary medicine is a very expensive proposition. You
can't ignore the cost of everything.
CHAIRMAN KASS: Let me give Michael the last comment.
And then you can have the last word, Dan.
PROF. SANDEL: Well, first, I hope you realize what a heavy
price I've paid for coming to your support, Dan. It's cost
me all of my friends here with the possible exception of Gil.
PROF. SANDEL: Contrary to what Leon suspects, what makes
me sympathetic to your proposal, it's not just or primarily
your emphasis on social solidarity and a critique of markets and
universal health care, all of which I agree with you on. What I
like about it is that those things are connected to something that
Gil emphasized, which is an underlying religious and/or moral conception,
which you haven't made all that explicit here. And I think
that's made things more difficult for you. But it is implicit
in your account. So that's one friendly suggestion.
The other is related. I wouldn't cast this as an argument
against progress. I would describe this as calling into question
what counts as genuine medical progress in human terms.
And, as I understand what you have in mind — and this fits
with Gil's proposal that there is a kind of moral or religious
understanding underlying this — that what you are proposing
is that we can't answer the question what counts as genuine
medical progress without asking questions about the nature of the
good life and normative conception of health. And we can't
sort those out without trespassing on some religious and substantive
If you put it more explicitly in those terms, well, you might
still lose some around the table, but you might tempt others.
DR. CALLAHAN: Let me just say one final word. I don't
think I've ever said I'm against progress per se. We will
go forward. Human beings change and always change. The question
is I absolutely agree, what is good progress and bad progress?
But by taking a political stance on it, we have already demystified
it a little bit. That's all.
PROF. GEORGE: Leon, if I could say just a very
quick — it's probably just a very quick word because I
want to say something about Dan's work in light of some of Paul's
I've been reading Dan's work for the 20 years I've
been in the academic business. It's filled with proposals.
Some of them I've agreed with. Some I've disagreed with.
I certainly commend Dan for making proposals, instead of doing
the kind of philosophy that there is too much of that doesn't
actually have a bottom line.
But I do want to say, even where I have disagreed, another one
of the things about Dan's work is it aims to put forward the
proposals to the public for democratic deliberation.
It's not, Paul, a question of elitism or imposing an expert's
opinion from on high. The proposals in Dan's work are proposals
for us to deliberate about and decide as a democratically constituted
people whether we're going to go down this path or not.
DR. MCHUGH: I've also read Dan's work
for a long time. And I agree that he is a Democrat and an American
and he believes in all of those things. He even wants to quote,
after all, polls. So that is a good thing.
I just think that behind it, behind these things, rests a presumption
that somebody knows better than the average guy what he wants.
And if that were turned loose in other directions, like Gil said,
we wouldn't have iPods because we don't need them. We wouldn't
have certain courses because we don't need them.
And it is embedded in there in the same way — and to some
extent, the great thing about the Webbs and the Fabians is that
they did have a moral persuasion. They just lost sight of their
CHAIRMAN KASS: I think we should call this one. Those
who are meeting for dinner, it's Bobby Van's restaurant.
I think it's 806 15th Street, a couple of blocks from here,
at 6:30, tomorrow morning 8:30. And we will be discussing the Council
draft White Paper on alternative sources of stem cells and then
a session on chimeras.
(Whereupon, at 5:37 p.m., the foregoing matter
was recessed, to reconvene at 8:30 a.m. on Friday, March 4, 2005.)